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Ask the Expert Welcomes Carl Siciliano

“Ask the Expert” features an interview with a leading expert on homelessness or co-occurring mental and substance use disorders. The following is an interview with Carl Siciliano, Executive Director of the Ali Forney Center.

We are pleased to welcome Carl Siciliano, a nationally recognized advocate and provider for homeless LGBT youth who has been dedicated to this population since 1994. In 2002, Siciliano founded the Ali Forney Center, which has grown to become the Nation’s largest and most comprehensive housing program for homeless LGBT youth. The Ali Forney Center offers emergency housing, transitional housing, a drop-in center, a vocational/educational center, and a mix of supportive services that help LGBT youth become successful, independent adults. Siciliano's work has also received extensive coverage in local and National print and broadcast media. In 2002, he was named by “OUT Magazine” as one of the 100 Outstanding Gay Achievers. His work has also been recognized by the Stonewall Democrats of New York City in 2006, and in 2007 he was awarded the Brooke Astor Service Award which is given to someone who is relentless in his or her dedication to the city of New York and who has contributed substantially to its enrichment.

Question: How do you incorporate recovery, homelessness, and behavioral health issues with the LGBT population?

Answer: All of our programs specifically target homeless youth and our program models incorporate a service-rich approach in which substance use and mental health issues are continually assessed and responded to from day one in milieu settings where we know LGBT youth congregate. We appreciate the need for qualified clinical staff and have integrated licensed social workers into all of our teams, including outreach. We also provide ongoing substance abuse and mental health training to our paraprofessional workers who are an integral part of our treatment approach. Our drop-in centers, which are popular spaces among street-involved LGBT youth, also house our licensed mental health and substance abuse providers on-site and are seamlessly integrated into the team. Although we have a harm-reduction approach in general, recovery is always the overarching goal as we work to move our clients from the streets to independent living.

Question: Which element, housing, support services…do you find most critical to LGBT recovery?

Answer: Without a doubt, housing is the most crucial need for a young person who is both homeless and suffering from co-occurring disorders. The stresses and instability caused by homelessness are overwhelming for anyone, but especially for a young person. Successful treatment requires that a client has a secure base to call home while working on the arduous tasks of recovery. It is a simple problem of hierarchy of need; housing first, then treatment, then recovery.

Question: Have you seen changes in the numbers of youth coming to you for services during the current economic recession?

Answer: Since the recession began in the fall of 2008, we have seen the number of homeless LGBT youth who seek our housing and drop-in services increase by approximately 40 percent.

Question: What are some of the evidence-based and best practices you use?

Answer: Although the leading evidence in neuroscience research shows that it is the warmth and acceptance of an ongoing, supportive relationship between client and worker that provides the best vehicle for successful change, we also employ some manualized practices that work well with our population. Street Smart is an evidence-based practice that we use to bridge our outreach services to our more intensive programming at our drop-in centers. This approach links education about HIV and risky behaviors to helping street-involved youth develop strategies for reducing risk and harm in their lives. We also employ Motivational Interviewing techniques throughout our case management services in all of our programs. We believe that this approach empowers young clients, while helping them to identify and work through their ambivalence about goals that at one point seemed to be out of reach. Ambivalence, or unconscious conflict, is an area that does not get enough attention in many manualized approaches, and yet we believe this is one of the most crucial elements to resolving blocks in achieving goals, including the goal of recovery.

Question: How have the issues with this population changed in the past 20 years since you’ve started working with them or haven’t they?

Answer: The core issues that homeless LGBT youth present have not significantly changed since I began to work with the population in 1994. Then and now, youth are traumatized by family rejection due to their being LGBT, and we see significant amounts of mental illness, substance use, and HIV infection. The changes that I have observed are that in the 1990s when homeless LGBT youth were becoming infected with HIV, they were usually being infected through sexual encounters with older adults; now many more are infected by their peers. We do see significantly less use of crack cocaine as a drug of choice than in the 1990s. Also, I would say that LGBT youth have more access to mainstream youth services than they did in the 1990s, when it was impossible for them to access shelter in New York City, though they still face significant barriers in the service system due to homophobia.

Question: What are some of the greatest challenges facing the LGBT homeless population?

Answer: I would say that the primary challenges facing homeless LGBT youth are (1) overcoming the trauma of family rejection, (2) the grossly inadequate service infrastructure available to them, and (3) the extent to which their ability to access the limited services available are negatively impacted by homophobia.

The youth we see have been told that their lives are worthless, that being gay makes them disposable, makes them unworthy of being loved by their own family. Youth, lacking the ego strength of adults, internalize those messages and act out their struggles with their basic worth as human beings in self destructive ways, particularly with use of substances and promiscuous/reckless sexual activity.

There are approximately 200 beds in the entire country dedicated to a homeless LGBT youth population that numbers in the tens of thousands. Even when LGBT youth are able to safely access mainstream youth shelters, there are far too few shelter beds available. Consequently the vast majority of homeless LGBT youth are stranded on the streets without access to shelter.

Very many of the homeless youth providers in the United States are religious-based. It is in and of itself problematic that LGBT youth are made to seek care from organizations affiliated with belief systems which teach that homosexuality is evil, and LGBT youth frequently experience barriers to care from shelter staff who are homophobic, and from other residents who subject them to anti-gay violence.

Question: Can you talk about suicide with this population and how Ali Forney is addressing this issue?

Answer: Suicide is a very significant risk in homeless LGBT youth. A recent study by Caitlin Ryan of the University of San Francisco found that LGBT youth who have experienced family rejection are 8.5 times more likely to attempt suicide than those whose families accept them. Other studies indicate that 62 percent of homeless LGBT youth admit to having considered or attempted suicide.

Because we have clinical support integrated throughout our continuum of services we are able to constantly monitor our clients for signs of severe depression and suicidality. We have observed particular risk when our clients test positive for HIV. Approximately half of our clients express suicidal thoughts after testing HIV+, and we frequently have to hospitalize them at that point. During the past nine years we have had between 50 and 60 clients hospitalized because of suicidal ideation, but thankfully, none of our clients have died by suicide.

Question: Partnering with Center for Social Innovation, what is involved, what are the goals and strategies to reach those goals?

Answer: The Ali Forney Center (AFC) and the Center for Social Innovation (C4) are pleased to announce the development of a National Center for Excellence on LGBT youth homelessness. AFC and C4 will partner with LGBT youth experiencing homelessness to translate best practices into tools for homeless service providers. We will pilot the project in the New York City area, and then scale it nationally. Specific activities include the development of online resources and an online peer-to-peer learning community; creation of Web-based training courses; custom technical assistance for individual programs; and face-to-face trainings. The goal of this partnership is to develop concrete tools and resources that homeless service providers can use to serve youth experiencing homelessness and identifying as LGBT—and ultimately improve the lives of these very important young people. In addition, we seek to help assist in the creation of additional housing and service resources for homeless LGBT youth around the country by assisting providers learn how to seek funding and design appropriate housing models for homeless LGBT youth.

Question: How did the program start, how do you get your funding, how do you decide what services/activities to provide to your consumers?

Answer: I founded the Ali Forney Center in 2002. We opened with a donation from a donor who gave us $37,500 and a church which gave us use of their basement for emergency shelter. Within a year I had assembled close to $1 million in funds, mostly from HOPWA (a subsidiary of HUD) and from local foundations focused on LGBT youth and HIV/AIDS.

We started by opening scattered site emergency shelters. We rented two residential 3-bedroom apartments and housed six youth in each apartment with staff supervision. In our first few years almost all of our funding was needed to support the costs of maintaining the shelters and we were unable to provide much in the way of supportive services. In 2005 we received additional HOPWA funding to support our first drop-in center, which enabled us to begin providing more substantial case-management, as well as on-site medical and mental health services and HIV testing and treatment. In 2005 we also received a HUD grant that enabled us to begin to provide a transitional housing program where our clients could reside for up to two years while they pursued vocational and educational goals. Also in 2005, as a result of substantial advocacy we did regarding the lack of New York City funding for homeless LGBT youth, we began to receive a New York City Council discretionary grant that has enabled us to expand our emergency housing, and our drop-in services. In the past two years we have received grants from the New York State AIDS Institute and the Federal Administration for Children and Families and the Department of Justice to expand our outreach services, and from SAMHSA to incorporate substance abuse treatment into our mental health services.

We deliberately determined to go after funds to support housing first, as this was the most pressing gap we identified in what was available to homeless LGBT youth in New York City. Since then we have attempted to support a full continuum of services to assist LGBT youth in escaping homelessness, becoming stabilized, and gaining the skills they need to become independent adults.

Question: What is the benefit for LGBT youth to go to LGBT youth programs as opposed to the mainstream programs?

Answer: We see that our clients thrive in an "LGBT-specific" space. Safe spaces for LGBT youth enable the creation of supportive communities where young people can gain a healthy understanding of what it means to be LGBT. As youth have been tormented with the narratives of homophobia they have been repeatedly presented with distorted, hostile visions of what it is to be gay, and of whom gay people are. We are described as evil, sinful, harmful to society, as perverts, as somehow apart and less than the rest of humanity. They have been taught to hate themselves based on bigoted ignorant misunderstandings of what it means to be gay. Our youths need to be exposed to the reality of LGBT people as actual human beings who are just as good, and just as flawed and just as real as all other human being so they can achieve an integrated understanding of who they are as gay people.

At the Ali Forney Center there are several different dimensions of community building that occurs. The youths build community with each other. We work hard to help the youth have empathy with each other, to be supportive of each other, to encourage each other in their struggle to overcome homelessness and rebuild their lives. Particularly in our housing sites we are gratified to see our youth often develop a sense of family with one another. Especially when youths have been cruelly cast out of their families, it is therapeutic and healing to find a healthy, accepting family environment.

Further correcting of the homophobic distortions of what it means to be LGBT happen as our youth develop healthy relationships with our staff and volunteers. Many of the homophobic narratives that have been forced on our youths are sex-obsessed. People and institutions that are homophobic are often unable to see LGBT people are real and fully dimensional. Their vision of us is defined by their fantasies of our sex lives.

At the Ali Forney Center our youths are exposed to a wide array of staff and volunteers who are caring, nurturing, and professional. They interact with LGBT people who are counselors, nurses, and bankers, ministers, photographers, journalists and even ministers; those interactions have nothing to do with sex, but rather with the altruistic desire to help and mentor young people in crisis. This exposure to healthy LGBT adults helps them to envision themselves growing into healthy adults. The role modeling that the youth receive as they meet real, caring LGBT adults is essential.

Of equal importance is the exposure our youth get to have of supportive straight staff and volunteers. As our youths meet and interact with the numerous straight people who assist in the operation of our programs, they come to realize that homophobia is only one way of reacting to being gay. Seeing the kind, compassionate acceptance that so many straight people demonstrate to them helps them to put the homophobia they experienced in their homes, schools and churches in perspective, making it seem smaller and more bearable.

Too many LGBT youths have been taught to hate themselves. Having spaces in their lives that enable them to build community with gay youth and adults, and with supportive straight people makes it possible for them to love themselves. Healthy communities save their lives.

Question: Do your clients provide input into your programs?

Answer: Yes, our clients have several routes to provide us with valuable input throughout our programs. Each of our residences holds weekly “Community Meetings” in which suggestions and feedback about the program is solicited from staff. In addition, our day programs have a “Client Council” where clients meet regularly to discuss matters of their concern, make recommendations for changes, and plan activities and special events to be sponsored by the agency. While we hope that every client feels that their needs are appropriately addressed at all times, we also have a grievance policy and procedure so that clients have a private way of providing us with critical feedback whenever necessary.